Psychedelic therapy and cancer: 5 Questions for oncologist Manish Agrawal

Agrawal discusses the clinical trials he’s overseen, and the role psychedelics can play in treatment for long-term illnesses like cancer.

Manish Agrawal has always been interested in the big, philosophical questions: Why are we here? And how do we make meaning while we’re here? Agrawal contemplated studying philosophy, but like many children of immigrants, he knew his family wanted him to pursue a different career. “Like a good Indian, I became an engineer and then a doctor,” he says. After majoring in engineering as an undergraduate at Auburn University and completing medical school at the University of Alabama, Agrawal did his medical residency at Georgetown University and a fellowship at the National Institutes of Health – and he managed to earn a masters in philosophy from Georgetown along the way. 

For 20 years, Agrawal worked with cancer patients as an oncologist. Then in 2017, he read  about Johns Hopkins’s research using psilocybin to treat depression and anxiety in cancer patients. He was intrigued by psilocybin’s potential to improve quality of life, and death, for his patients. For Agrawal, psychedelics bridged his oncology work with his philosophical interests. Now, Agrawal is a co-director of clinical research at Aquilino Cancer Center in Maryland, and chief executive of Sunstone Therapies, a company conducting psychedelic therapy clinical trials. The Microdose spoke with him about the clinical trials he’s overseen, and the role psychedelics can play in treatment for long-term illnesses like cancer.

You’ve seen thousands of oncology patients. What role does mental health play during diagnosis and treatment?

When I give talks, I talk about the idea of an iceberg. Above the water is chemotherapy, surgery, and radiation, and underneath the water are what I call psychospiritual issues. Most of the time, as oncologists, we stay on top of the water — that’s part of our training. But if you look at the numbers, 15 to 25 percent of cancer patients have anxiety or depression. As an oncologist, I think the rate is actually much higher than that. It seems almost impossible to receive a cancer diagnosis and know that it is  potentially going to limit how long you’re going to live, or cause you to lose control of your body and experience physical symptoms, without contemplating the big questions about life and death. 

What have you found in your clinical trials where cancer patients receive psilocybin-assisted therapy?

Eighty percent of participants had a greater than 50 percent reduction in their depression symptoms based on MADRS, a depression rating scale. After treatment, half of the participants had what we call a complete response, which means that their MADRS scores were the same as someone who didn’t have depression. 

But what was the most powerful thing was to see the stories and the healing occuring. People were able to make sense of what was going on in their life. There was one patient I’d seen for some time that had a very difficult experience with the psilocybin treatment, both mentally and physically. But a few days later, she went to a lake – it was a fall evening, and as the sun was setting, it got really loud as the crickets started chirping. A sense of peace came over her. What came into her mind, she said, was that when she was born, there were all these humans, and over her lifetime, they died. She thought, When I die, there will be more humans. It’s just like how these crickets will all die come winter but in the spring, there will be a whole new crop of crickets. I’m part of the natural cycle of things; it’s not about me, personally. 

Some psychedelic-assisted therapy studies treat patients with one-on-one therapy, but in this trial, patients underwent group therapy. How did that work?

The study involved individual but simultaneous psilocybin sessions — they were in separate rooms but the rooms were right next to each other — and they found comfort in having other people go through it with them. Some people said that hearing someone next door crying opened up their own ability to get in touch with their own sadness. 

Then after treatment, they had group therapy. That brought them together, and they found a lot of support in one another. The trial ended after eight weeks, but they decided to keep meeting. It’s now a year and a half later and about half of them still attend a monthly Zoom. 

Undergoing cancer treatment is difficult for patients, and that also affects their loved ones, and their medical care staff. Could psychedelic-assisted therapy be helpful for families, caregivers, or medical professionals supporting cancer patients?

Caregivers and families are so profoundly affected by a cancer diagnosis; especially if a person passes, sometimes that doesn’t get reconciled for 20 years. We just opened up a study giving MDMA to cancer patients and to affected family members. There are two therapists to talk to each of them about how cancer has affected their relationship and the family. The idea here is that you can’t really treat the person alone – the ripple effect is huge. 

During the clinical trial, it was so helpful for us – the oncologists, therapists, and nursing staff – to be a part of the study. We felt it addressed an unmet need for patients, and to see you’re making a difference addresses your own burnout. There aren’t any trials in the works yet, but we’ve been in conversation with Anthony Back at the University of Washington, who is looking at whether psilocybin helps frontline workers recover from COVID-related burnout. I’ve had nurses tell me, “If you ever open up trials for staff, we’re in.” 

Access to psilocybin-assisted therapy in the U.S. is still quite limited; many people want to be a part of these clinical trials but there aren’t enough spaces. Meanwhile, cancer patients like Erinn Baldeschwiler are suing the DEA for access. What do you think are the next steps for more accessible therapy?

I’ve been somewhat frustrated at times by the lack of access. The Right to Try avenue is important, as is what’s happening in Oregon with a regulated system. I’m working mainly through the medical model, and there are real barriers there. For instance, have you ever heard of ICD-10 codes? If you want a good laugh, Google “funny ICD-10 codes” – they’re the codes used in medicine for diagnoses and billing. There are ones for breast cancer or diabetes, but also ones like, “sucked into a jet engine,” “bitten by a pig,” or “pedestrian injured in collision with a rollercoaster.” In talking with Usona, or COMPASS, or any of the pharma companies, they need a medical diagnosis in order to develop a drug, and there’s no ICD-10 code for cancer-related depression. The pushback they get from regulators is, “Well, this is just a treatment for depression — why have anything special for cancer depression?” There are some conversations happening with regulators about this, because there is a difference between depression and cancer-related depression and how to treat it. The cancer depression experience is complicated; there are questions probing identity, which is brought on acutely by a diagnosis that says there’s an hourglass here and you don’t know when it’s going to run out. 

I don’t think psilocybin is a magic bullet, but it’s a very powerful medicine, and I’m convinced that the delivery and support is going to be as important as the drug. 

This interview has been edited and condensed for clarity and length.